Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Monday, September 04, 2006

Breast Cancer: scary tales

Here is a truism by which I've always stood in my breast practice: an excellent way to investigate a palpable (feelable) breast lump is "fine needle aspiration." In fact, I'm a bit of a fanatic about it: I think gazillions of dollars are wasted by unnecessary breast ultrasounds for lumps, and by more extensive biopsies than -- in many cases -- are needed. I'm happy to say I was a bit of a burr under the saddle to many a radiologist, and some primary care docs as well, as I tried to spread the word. (In one particularly enthusiastic moment, during a joint conference between surgeons and radiologists to address such issues, I dis-ingratiated myself by saying, "When all you have is a hammer, everything starts to look like a nail.") I tried -- ultimately unsuccessfully, I'll sadly admit -- to convince primary docs that when they could feel a lump, the first stop ought to be at the surgeon's, not the radiologist's store.

A breast lump is either solid or liquid. For the most part, that's all an ultrasound can tell you for sure. At considerably less than half the price, a surgical consult with needle aspirate will give you that, and much much more. Poke a fine needle (size of one used to draw blood) into a lump: if it's liquid it's nearly always a harmless cyst, in which case the needle withdraws yellow clear fluid, proving the diagnosis and making the cyst go away, usually permanently. Same info as the ultrasound, along with therapy. If the lump is solid, the needle can remove a tiny sample, which, properly spread on a slide and given to a pathologist skilled in such things, can be very accurately assessed. When a lump is cancer, the needle sample either shows cancer, or some cells that are highly suspicious. And when the sample shows entirely innocent cells, and when the lump in question is clinically innocent (as judged by a competent examiner), the chance of missing cancer is extremely low, in which case followup without further biopsy is often a satisfactory option. Few things -- medically speaking -- bug me more than seeing a woman who's had an ultrasound that shows a cyst, referred for treatment. Had it been the other way around, the ultrasound would have never been needed. Even worse is a woman who had a palpable lump, sent first to radiology and getting a mammogram followed by an xray guided (stereotactic) biopsy. Huge waste of time and money. (I may post about diagnostic issues again and get back to this. For now, suffice it to say that stereotactic biopsy is an excellent tool for a NON-palpable lump. And, along similar lines, I'd say this: a mammogram is to find things we can't feel. When a lump is feelable, it makes more sense to me to see the surgeon first: for example, if it's a cyst, and I drain it, what's the good of having taken a picture? It'll be gone on the next one!..... It could take several posts -- or a hellaciously long one, to cover this well.)

So here's the drill: if I saw a lump, I'd generally poke a needle in it. Takes literally about five seconds, hardly hurts. If I'd get clear yellow fluid, and if the lump went away completely, I'd tell the woman with total confidence that it was a simple cyst, explain exactly what that means, arrange followup, and flush the fluid. (It used to be routine to send the fluid to the lab. But several studies confirmed what I'd come to believe: if clear yellow, and associated with a disappeared lump, the tests never showed a thing. So tossing it away became the marching order.) If the lump was solid, I'd sample it with the needle, make a slide, and send or carry it to the pathologist. And when I was sure it was cancer, the sample virtually always showed it. I'm efficient as hell, with a woman's time, and money. But I got two surprises in one week, and they were close to disastrous.

When I saw the referral came from a family doc who always used someone else, I thought this was gonna be something strange, and indeed it was. She'd done a needle aspirate (good for her!) on a young woman with a lump, had gotten clear yellow fluid, observed the disappearance of the lump, but sent the fluid to the lab. And had gotten back the diagnosis: cancer. I was stunned, and deeply disturbed. It was against everything I believed: I'd tossed tens of hundreds of fluid sample into the trash. How could this be? I called the lab, I talked to the lab doc. Was there any chance of an error, a mixup of labels, anything to explain it? There was not. I asked them to double check. They did; there was not. When I examined the woman, the site of the needle poke wasn't visible, and there were no lumps. The doc couldn't say with precision where the lump had been. The mammogram was normal as could be (she was young enough -- early thirties -- that mammograms aren't all that useful, anyway.) Just to make it all more interesting, she was an attorney in the DA's office. To say it was disquieting is to understate by a factor of a pants-full. The woman evidently had cancer, despite the diagnosis being counter to a fundamental principle of my practice. In fact, I already had reason to question my whole approach: I'd just done a needle aspirate on a little old lady who I was absolutely convinced had cancer, and it had come back totally innocent. I must have missed the lump by a mile: me, who made a crusade about the method. Not even my fellow surgeons used it as much as I did. I'd had to do a more expensive, more invasive open biopsy on the lady to confirm the diagnosis of cancer...

Getting goose-bumps yet? It all became clear, about a day or two after I operated on the young attorney. I'd removed the entire quadrant of the breast in which the "cyst" had been, and had done a small lymph-node sampling under her arm. The good news is that because the breast (properly managed, if I may say so) can end up with very satisfactory contour after a pretty large lumpectomy, she got a nice cosmetic result, other than a fine scar. The pathology report, which showed absolutely nothing out of the ordinary, came about the same time I got a phone call: they'd pursued it further and discovered a lab mixup: the slide made from the cyst fluid, and the slide I'd made from the little old lady had been confused by the lab. They even acknowledged that mine had -- as always -- arrived from my office properly labeled and marked and that the error was entirely theirs. Without being asked, the lab doc sent a letter to my patient explaining exactly what had happened, and that I'd twice asked them to double-check. She was surprisingly gracious. And my little old lady, who indeed had cancer, did well despite having undergone an unnecessary open biopsy before her definitive treatment.

And here's the thing: these aren't even the worst stories. I once did a biopsy on a lymph node under the arm of a woman in her seventies. Metastatic breast cancer, was the report. No ifs, ands, or buts. The mammogram, the physical exam were normal. It's uncommon but not entirely rare, and the concensus is that the treatment is mastectomy on the affected side, with around a 60% incidence of finding the cancer in the removed tissues. I was in the recovery room writing post-op orders, having done just that, when I got a call from the pathologist. "Hey Sid, this is Dave. Just got the report from the university. Remember that lymph node? They said it was melanoma. Guess it's lucky we waited, huh?" "WAITED!!!! WHAT THE F--- ARE YOU TALKING ABOUT???? I just took her breast off!!" "Jesus," Dave said. What happened is, they have a weekly cancer pathology conference, at which -- after the final and unequivocal report had been sent out -- another pathologist (he's the one to whom I always carried my breast aspirates -- the best I've ever seen. He was out of town during the week of the first two cases...) had said he thought it might be melanoma. They'd decided to send the slides for consultation, but hadn't bothered to let me know... I said "Dave, you are coming with me when I talk to the lady." Dave said..... well, I don't remember what he said. But he came.

What's the lesson here? Damned if I know. I was inspired to write this after reading the latest post at Urostream. If good news isn't always good news, and bad news isn't always bad, I guess you have to hope to hell you have a team that talks to each other.

18 comments:

thats mildly disturbing...lab mix ups and lack of communication, oh my!i work front desk now, but since i got done with medical assistant school i worked in a dematology clinic for about 8 months, and the did lots of temping. while at the derm clinic, we had a temp come in for a week. she was awful. we did lots of biopsies, and they had to be clearly, proerly labled, and done so in timely fashion. she didnt do that. at the infectious disease clinic i work at now, we send people for blood work all the time. in one case recently, at a lab we dont use often, a blood sample was left on the counter all day because a snippy lab tech didnt believe they could do the test requested. it was a test routinely done by our usual lab. of course, the sample was completey ruined, and the draw had to be repeated, and the pt lived miles out of town...and our nurse was furious. not as bad as your stories, but still, there has to be absolute accuracy and efficiency in these things, because they involve a persons time, money, and most of all well being. i cant belive there can be such mix-ups likw these. 'the devil is in the details'.

In the end, it's all about the honesty. The honesty to admit a mistake when it happens. The honesty to realize that everyone one is fallible, that if I become excessively angry at someone else's fallibility, I will sooner or later have to answer for my own.

When you get a lab result that's so different from what your clinical experience indicates, is it maybe a good idea to repeat the lab test, when that's possible? (Not sure what you'd do about the aspirated-and-disappeared cyst.) And maybe it's also a good idea for physicians as well as patients to ask for a second opinion, ideally on a new specimen or on both a new and the original.

Holy moly, though. Ow. As I've visited a couple of local labs for services in the past few years, and noticed how chronically understaffed they are, I get even more nervous about relying on them.

I am in kingston jamaica and my email is naudia_wrightthomas@yahoo.com. I have just 2 days ago discovered that there is a yellow liquid coming from my right breast and I am scared. I am going to the doctor today. However, based on your article, please tell me what the first step is.

I have a question...I have a breast lump...located directed under a familial mole. Finally, got someone to listen to me...as the OB/GYN ruled at first had to be skin/mole related...Dermatologist ruled Breast related, and was going to shave it off....Mammogram and sonogram findings have lump at BIRADS 4. Biopsy and lumpectomy are Thursday. What should I be looking for from the surgeon? Is removing this and the surrounding tissue, the right course? Should there be a more aggressive treatment? And finally, could this be a totally freaky benign situation?Thanks Heather...

Heather, I'll post here the response I sent you in reply to your email:

It will all depend on what the biopsy shows. All you have learned from the studies so far is what you already knew: there's a lump. It will be getting a tissue diagnosis, which is appropriate. It could be benign, in which case it wouldn't need "aggressive" treatment. If it were to turn out to be cancer, then there are various options which, I'm sure, would be discussed thoroughly.

Dr. Sid:I'm a pastor, so I'm into a different therapy. But, I'm a huge fan of surgeons. They have created an airway for my 11 year-old who - at one time - had a completely occluded trachea due to acquired subglottic stenosis (premature birth and subsequent ventilation at 29 weeks gestation) and lived with a trach for 5 years.Anyway... prayed for a woman with two masses in her breast. Diagnosis came from routine mamogram. One was clearly a large cyst. The other was solid. The gyn decided to wait for 6 months. Then, suddenly called back and referred to surgery. On the Monday following the Thursday of diagnosis, the surgeon recommended ultrasound and biopsy. The technician immediately found the cyst and confirmed but could not find the other mass. The radiologist had the same result after tons of manipulation and looking. Final diagnosis... nothing to diagnose.I obviously want this to be a supernatural event. What other questions do I have to ask to be honest about that? I guess that repeated compression of a cyst could easily cause rupture and disappearance. Could the original diagnosis of solid mass be mistaken? Thanks!Pastor Dave

Pastor Dave: cysts often come and go. As to a "mass," it's a matter of interpretation: mammograms show all sorts of densities, the interpretation of which can be subjective. "Mass" is nearly a meaningless term, out of context.

I've seen many a mammogram that was over-read by one radiologist or another (better that than under-read), and have seen many shadows present at one time and not at another. This is especially true in women who are younger than menopause.

And I've had several patients show up for an xray-guided biopsy, for "something" not palpable that showed on xray, only to be told it was no longer there. It happens. I'm sure some of them were praying. They were also going through normal hormone cycles.

One of my constant struggles was advising women who'd had a mammogram interpreted as a "mass" when I considered it just asymmetrical density, common in lots of women, especially those with fibrocystic changes. Not a comfortable or easy situation.

Here's a comment I just received. I'm reprinting it to remove the email address:

I hope that I am finding this helpful and informative. I am not quite sure what to do and no one seems to know. I have a small limp that is rather superficial (but so are my breasts, I do not fill most A's) I first noticed it months ago, probably last summer. It was a dark spot that just wasn't quite the color of a mole or freckle. It is a dark, blackish sometimes slightly bluish lump just under the skin. I have mostly ignored it but decided maybe I should get it looked at before I switch insurance. The NP thinks it is likely nothing to be concerned about but ordered a diagnostic mammogram and ultrasound just in case. I asked if was really necessary if she really doesn't think it is anything to worry about. She said that they have been fooled before so she still thinks I should do the tests. Probably naturally I have been paying a lot of attention to the spot-lump since. Though the discoloration is always there the lump is virtually non-exisitant in the mornings. It is very round in shape and depending on the time of day probably 3/10 to just under 1/2centimeter in diameter. In your oppinion is a mammogram and/or diagnostic ultrasound the best course of action (though your opinion seems clear)? Could it be related to a blood vessel? and if you think it would be best to do the needle prick thing how do I go about discussing or explaining and/or requesting this to the Dr. / NP?I would so appreciate your professional advice and oppinion. I have found no information about anything like this little spot-lump. Money is an issue as I am changing from a high deductable insurance plan to an even higher deductable plan. I really don't want to spend a ton of money on satisfying curiosity. Oh and I am 32 years old so it sounds as though a mammogram might be moot anyway. You can contact me by e-mail at (----) and though I don't mind this being published on your blog I would prefer that my e-mail not be out there. thanks so much.

It could well be a cyst, and, as I've described in my writings here, my approach with most masses was to insert a needle as a first step: if it's a cyst, it will disappear along with the return of some clear yellow fluid. If it's not a cyst, the needle will usually provide a small sample of the tissue that can be analyzed under a microscope.

I agree mammography isn't very likely to help with the item you're describing, but that's not to say a mammogram is not indicated.

Finally, I can only provide general information about my approach; there's no way for me to have enough specific knowledge of an individual situation to provide direct advice. It must be, and can only be, between you and your doctors.

But do you have any advice on how I could or should bring up checking it the way you would (with just a needle) ti my Dr? It was never mentioned at my appointment and does not seem to be a common practice. I somehow happened apon your blog otherwise I'd not be aware that was a possiblity (though I had even mentioned to my husband that I think they should just stick a needle in it and see what they get, it seems more common sense after reading your blog) I would like to opt for trying something like that first but I am not sure how I would suggest this. What would I call it? How would I get them to take me serious and consider it? My experience has been that Dr.'s seem to get set in certian methods and ways and do not like to be told otherwise by a mere patient. (from this blog entry it would seem they don't even like to listen to educated knowledgable surgeons, you, either)Do I just tell them this is what I want them to do first? And if there is resistance or the look, then what would you suggest?I know that you can not give me a medical diagnoses or anything but I would like your advice. My description was hoping that you had experience or knowledge of spot-lumps of this kind. Though you being a sergeon and not having seen anything like it would be very encouraging.Again any advice would be so appreciated.P.S. your blog is pretty cool thanks for sharing.

I'm sorry not to be of more help, but I think I've said all I have to say without feeling like I'm intervening between you and your doctor. Needle aspiration of breast cysts and other lumps is not uncommon and I'd think you could say you've read about it and wonder if it would apply to your situation. Beyond that, I think you have to decide if you're comfortable with the explanations you receive: I repeat that the interaction between you and those who know you is much more trustworthy than those with someone on the other side of your computer screen.

36 yr old Femalepalpable tender lump 9:00 rt breastmammogram - negativeultrasound reveals a subtle, approx. 1.6cm area of mildly hypoechoic apparent architectural distortion. Assessment: BIRAD 4CNB- Benign. Fibroadenomatoid and fibrocystic change. Radiologist recommends excision or contrast MRI. OB/GYN says she wants it out, and I would like it out as well. QUESTION: Is there a significant difference between fibroadenoma and fibroadenomatoid? Should I be worried about a "missed" cancer in this case?

Jennifer E: I'm not sure I've seen the word "fibroadenomatoid" in an xray report, or even heard the word before, but I'd assume it's sort of a fudge, meaning fibroadenoma-like. Benign, in other words. But I can't know for sure: if it would make a difference in your decision-making, you should ask your doctor to clarify or get a clarification from the radiologist.

Great. I haven't been able to find much on the internet regarding fibroadenomatoid, except "fibroadenomatoid hyperplasia." I'm going to assume for now that it's just like you said - similar to fibroadenoma. Thank you for your response. I'll ask the surgeon on Monday.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.